Untangling the Asian Enigma

In the past two decades Bangladesh and Nepal have achieved striking improvements in the nutrition of their citizens. How did they do it?

Children in Nepal once had one of the world's highest rates of stunting, but the country has made rapid progress in improving children's nutritional status.

In the late 1990s and 2000s, something extraordinary happened in two of the world’s poorest countries. As child stunting—when children are too short for their age, indicating poor nutrition—inched downward in richer countries, Bangladesh and Nepal managed to cut their sky-high rates of stunting by a third. Their success was unexpected and unexplained.

Even more surprising is the fact that Bangladesh and Nepal made much faster progress than their South Asian neighbors. People in South Asia suffer from higher rates of malnutrition than one would expect given their incomes, and researchers are still struggling to understand the causes of this “Asian enigma.” While India achieved modest improvements in child stunting in the 1990s and 2000s and Pakistan and Sri Lanka recorded no improvement, Bangladesh and Nepal pushed rates down from about 60 percent to about 40 percent—still high, but no longer among the world’s highest.

According to Derek Headey, a senior research fellow at IFPRI, it was not just one action that made the difference in either country. Poor nutrition is a multidimensional problem that can’t be solved by a health or food intervention alone. Many things need to go right, and in Bangladesh and Nepal, says Headey, “a bunch of things were going right.”

More Than Economic Growth

How did the two countries suddenly make great strides in key nutrition outcomes? In a recent paper on Bangladesh and another on Nepal, Headey and several IFPRI colleagues have tried to identify exactly which factors contributed most.

For starters, they found that both countries achieved this success without enjoying the extraordinary economic growth witnessed in, for example, China or Vietnam. To be sure, Bangladesh’s “green revolution” of the 1990s made rice production more profitable: farmers used new rice seeds, and the introduction of widespread irrigation made the dry season more fecund. In Nepal, growth in the agricultural sector—which employs most poor people—was robust, at nearly 4 percent a year from 2001 to 2011. Increased remittances from relatives overseas also played an important role in both countries.

But Headey points to other factors that better explain the declines in child stunting. “There was significant improvement in health, education, and family planning,” he says. “It was broad. Without having stunning economic growth rates, they managed to achieve broad social change.”

Many Things Going Right

One change involved building more toilets—and getting people to use them. In Bangladesh, the Community-Led Total Sanitation initiative helped dramatically lower rates of open defecation, which can lead to the spread of parasites and bacteria that worsen nutrition and cause stunting. The proportion of villages with no toilet fell from almost 25 percent in 1997 to just 4 percent in 2011. Families also learned better feeding practices for their children. The share of children aged 6 to 9 months who were introduced to solid foods—which should be universal by that age—rose from a paltry 22 percent in 1996/1997 to around 70 percent by 2004.

Girls’ education helped too. In the 1990s, few girls went to school in Bangladesh, but now, says Headey, girls overall have more years of schooling than boys. Girls’ education is associated not only with better nutrition, but also with improved infant mortality, maternal mortality, immunization, and family planning.

In Nepal, the researchers identified four factors that led to change: Households acquired more assets and thereby improved their material well-being. The government invested in effective health and nutrition interventions, including increased antenatal care and iron supplements for women. Mothers benefited from more education. And sanitation improved significantly. Like Bangladesh, Nepal adopted Community-Led Total Sanitation, reducing rates of open defecation from 75 percent in 2001 to 42 percent in 2011.

Remarkably, Nepal achieved these advances in the midst of a civil war and political instability. “When you consider that,” Headey says, “Nepal is a phenomenal story.”

Ultimately, if Bangladesh and Nepal continue pushing down the share of children who are stunted, the result will go beyond simply taller children. Good nutrition early in life pays dividends by giving people stronger immune systems, increased cognitive ability, higher levels of educational achievement, higher productivity and wages, and longer life expectancy. “This kind of human capital accumulation,” says Headey, “is one of the foundations of sustained and transformative economic development.”

Although South Asia has the highest concentration of undernutrition in the world, in the past two decades Bangladesh and Nepal have both achieved striking improvements in the nutrition of their citizens. How did they do it?